Apparatus and method for arthroscopic transhumeral rotator cuff repair

ABSTRACT

Apparatuses and methods are provided for arthroscopic rotator cuff repair incorporating a transhumeral bone tunnel. The apparatus comprises a number of components that can also be considered a repair system to include a drill guide, a marking hook, and a drill with a removable tip that serves as a bone anchor. In another aspect, the invention provides a suture especially adapted for securing both soft tissue and bone anchors that reduces forces transmitted to the anchors by secondary anchoring of the suture within the bone tunnel based on the geometry of the anchor. In additional aspects of the invention, the components of the drill guide assembly comprise a cannulated marking hook and a drill guide with multiple bores. In additional aspects of the invention, an implantable bone anchor is provided that is especially adapted for placement through a bone tunnel, and wherein the implantable anchor is collapsible to increase the effective size of the anchor for securing the anchor to the far side opening of the bone tunnel through which the anchor was placed. Methods of the invention include a method of arthroscopic repair of a rotator cuff, and methods of activating an implantable anchor.

FIELD OF THE INVENTION

The present invention relates to surgical devices and methods for repairof torn tissue, and more particularly, to an apparatus and method forrepair of a damaged rotator cuff by transhumeral suture anchoring in anarthroscopic procedure.

BACKGROUND OF THE INVENTION

Rotator cuff injuries are a very common injury suffered by patents ofall ages. A torn rotator cuff typically requires a surgical procedure toreattach the torn tendons to the bone of the humeral head. Rotator cuffinjuries are particularly bothersome in that the torn tendons must behighly stabilized in order for healing to occur.

In recent years, the preferred solution to ensure proper healing of arotator cuff is to increase the number of anchors used to secure thetorn tissue to the bone. Although increasing the number of anchors usedin the procedure can result in improved healing, there are also a numberof drawbacks associated with the increased use of anchors, most notably,the cost of the procedure.

One known prior art surgical technique for repair of a rotator cuff isthe use of a plurality of suture anchor screws that are placed in thehead of the humerus bone. The sutures are then threaded through theanchor screws and are passed through the rotator cuff tissue andoverlying musculature, resulting in a web of suture strands that aretied to one another thereby reattaching the rotator cuff to the humerushead. One particular disadvantage with this known type of rotator cuffrepair is that the plurality of screws is secured within the cancellousbone mass beneath the near cortex of the head of the humerus. This bonemass in the humerus head is particularly susceptible to osteopenicdegradation in which the bone density can significantly diminish,particularly in older patents. Accordingly, anchors placed in thisdegraded cancellous bone mass do not remain stationary, and some degreeof pullout or loosening will occur, thereby preventing proper healing ofthe tendon tissue to the bone.

Two references that disclose apparatuses and methods of rotator cuffrepair that do not locate the anchors within the cancellous bone mass ofthe humeral head are the U.S. Pat. Nos. 6,013,083 and 6,206,886 toBennett. These references disclose a method wherein a bone tunnel isformed completely through the humeral head extending to the far cortex.An anchor is located at the far cortex within the bone tunnel andsutures are attached to the anchor and extend through the bone tunnel.More specifically, these references disclose an apparatus and methodwherein a cannula is inserted through the skin substantially to the torntissue. A drill guide is inserted in the cannula, a drill bit isinserted in the drill guide, and a hole is then drilled through the torntissue and completely through the humeral head. The drill bit is removedand an inner cannula is passed through the drill guide until its distalend is engaged in the torn tissue or alternatively passed through thehole until its distal end is at the far end of the drilled hole. A softtissue anchor having expandable wings at its distal end and suturessecured to an eyelet at its proximal end is releasably connected to thedistal end of a tubular deployment tool with the free ends of thesutures extending through the deployment tool. The deployment tool ispassed through the inner cannula and drilled hole until the expandablewings clear the far end of the hole a sufficient distance to allow thewings to expand to a diameter larger than the diameter of the drilledhole. The deployment tool, inner cannula, drill guide, and cannula areremoved and tension is applied to the sutures to engage the expandedwings of the anchor on the exterior surface of the bone surrounding thedrilled hole. A button is run down the sutures through the cannula andsecured on the torn tissue by the sutures such that the torn tissue issecured to the bone and the sutures are anchored to the hard exteriorsurface of the bone by the expanded anchor.

It is also known within arthroscopic procedures to provide a drill guidein order to selectively drill a tunnel through bone in a precise,directed manner such that the bone tunnel can be used to pass sutures toan anchor located on the far end of the tunnel. Two known referencesthat disclose drill guides for drilling tunnels in the tibia forreplacement or repair of knee tendons include the U.S. Pat. Nos.5,112,337 and 5,350,383.

Although the drill guides of these prior art references are well knownfor arthroscopic repair of knee tendons, these drill guides have beenlimited to use with the knee joint, and have not been used as drillguides for other joints.

With respect to repair of a torn rotator cuff, there is still a need toprovide an apparatus and method in which the procedure conducted isminimally invasive, minimizes the amount of required hardware, yet is areliable, repeatable procedure. There is also a need to provide such aprocedure in which anchoring of the sutures is achieved by bypassing thecancellous bone mass on the humeral head, and taking advantage of thefar cortex of the bone that has a higher density therefore providing abetter means to anchor the sutures.

SUMMARY OF THE INVENTION

It is therefore an object of the present invention to provide anapparatus and method for repair of torn rotator cuff tissue whereinsutures are anchored along the far cortex of the bone thereby bypassingthe cancellous bone mass.

It is yet another object of the present invention to provide anapparatus and method in which the procedure can be conducted in aminimally invasive manner by minimizing the number of suture passesthrough the soft tissue, yet ensuring that the sutures are suitablyanchored in both a far bone anchor point, as well as a near anchor pointin the soft tissue surrounding the rotator cuff.

It is yet another object of the present invention to provide anapparatus and method in which a drill guide can be used to preciselylocate bone tunnels to be drilled, and the drill guide is easilyadaptable for use with patients of differing sizes.

It is yet another object of the present invention to generally simplifythe surgical procedure of a repairing a torn rotator cuff repair inwhich not only is the amount of implanted hardware reduced, but also theprocedure is simplified by minimizing the surgical tools required toconduct the procedure.

It is yet another object of the present invention to provide varioussuture constructions and suture anchor constructions that facilitate theapparatus and method of the invention.

The above objects and other objects of the invention not specificallyarticulated are accomplished by the present invention that includes anapparatus and method for repair of torn rotator cuffs.

In accordance with the apparatus of the present invention, a drill guideand drill are provided that are especially adapted for repair of a tornrotator cuff. The drill guide includes a marking hook that is especiallyadapted for the shape of the humeral head such that a bone/transosseoustunnel can be drilled completely through the humeral head. The drill ofthe present invention includes a drill bit tip that is used to drill atunnel through the bone mass, and then serves as the suture anchor. Thedrill bit tip includes a transverse aperture that can be held by themarking hook, and the drill shaft is then removed from the drill bittip. The drill bit tip is rotated to extend transversely across theopening formed on the far side of the bone tunnel, and then sutures arepassed through the bone tunnel and are secured to the drill bit tipthrough the aperture of the drill bit tip. The surgeon may then choosethe type of soft tissue anchor to be placed on the rotator cuff andmusculature surroundings of the rotator cuff. The marking hook can becannulated as by incorporation of an orifice extending through themarking hook, to thereby allow passage of sutures within the markinghook. After drilling across the humerus, sutures can be passed throughthe orifice of the marking hook. The suture can then either be passedinto the opening of the drill tip or can be grasped by a device placedacross the bone/transosseous tunnel.

Also in accordance with the present invention, the method of the presentinvention contemplates a cortical bone bridge in which two or more bonetunnels can be drilled through the humeral head, and then the suturescan be passed through the bone tunnels in the desired pattern forsecuring the torn rotator cuff tissue.

In yet another aspect of the present invention, a particularlyadvantageous self-anchoring suture is provided. This self-anchoringsuture incorporates a dispersed pattern of protuberances or beads thatcan be passed in a specified direction through the bone tunnel butprevent pullout by force applied in the opposite direction.

An additional suture configuration provided to accommodate thetransosseous aiming apparatus of the present invention is a sutureconstruction having a mesh-like structure mounted to a conventionalsuture. The mesh structure is initially rolled tightly around thesuture, and then unfurled after the suture ends have been deployedacross the humerus and tied along the medial far cortex. The mesh couldbe a scaffold of any synthetic material or biologic material. The meshconstruct could be rolled tightly around the conventional suture,contained in a sleeve, or rolled into place along the body of theconventional suture. The mesh can be provided in various lengths andwidths, and would provide “canopy” coverage of the cuff tear. Theinterface of the canopy and the cuff tendon underneath could be imbuedwith biologic growth factors or other substances to promote healing.

Another far-cortical anchoring device that can be used with the aimingapparatus of the present invention is a compression fixation anchor thatis formed as a cylinder with sutures placed through small holes formednear the distal end of the cylinder. The anchor body has longitudinallyextending cuts or slits, and the anchor body is scored circumferentiallyto allow folding or collapsing of the device at its mid-portion. As theanchor collapses, it becomes much large in circumference. One method ofadvancing the anchor is to place a nitinol wire through the transosseoustunnel, and then advance the anchor down the nitinol wire in acannulated fashion while retaining the suture ends. Once the anchor isin the glenohumeral space, tension is applied on the sutures, causingdeployment of the wider mid-portion of the anchor. Another method ofadvancing the anchor is to employ an inserting device through the tunnelin which the anchor is mounted to a distal end of the inserting device.For activation of the anchor, the inserting device can remain engagedwith the anchor, the sutures are tensioned, and the anchor deploys as itcollapses.

These and other features of the present invention will become moreapparent from a review of the following detailed description taken inconjunction with the drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a plan view of a drill guide assembly of the presentinvention;

FIG. 2 is a greatly enlarged fragmentary perspective view of a portionof the drill guide assembly including a bone drill used with theassembly;

FIG. 3 is an enlarged fragmentary exploded perspective view of the bonedrill;

FIG. 4 is a perspective view of the drill guide assembly positioned foruse in a surgical procedure for repair of a torn rotator cuff;

FIG. 5 is a perspective view of the patient's shoulder area shown alsoin FIG. 4, illustrating a bone tunnel as drilled by the drill guideassembly, and the drill bit tip being used as an anchor for sutures;

FIG. 6A is a greatly enlarged portion of FIG. 5 illustrating the drillbit tip used as the anchor;

FIG. 6 B is another greatly enlarged portion illustrating an alternatesuture arrangement for emplacement of the drill bit tip as an anchor;

FIG. 7 is a greatly enlarged perspective view of a suture especiallyadapted for use in the apparatus and method of the present invention;

FIG. 8 is another greatly enlarged fragmentary perspective view of apatient's shoulder area illustrating a pair of bone tunnels, and pairsof accompanying hardware to include corresponding bone anchors and softtissue anchors;

FIG. 9 is a plan view of a drill guide assembly and a cross sectionalview of a cannulated marking hook of the assembly in another embodimentof the present invention;

FIG. 10 is a plan view of an alternate embodiment for a drill guide ofthe drill guide assembly wherein the drill guide includes a pair ofoffset bores;

FIG. 11 is a cross sectional view of another embodiment of a cannulatedmarking hook of the drill guide assembly;

FIG. 12 is a greatly enlarged perspective view of an implantable anchorin another aspect of the present invention;

FIG. 13 is another perspective view of the implantable anchor of FIG.12, illustrating sutures attached to the implantable anchor;

FIG. 14 is a perspective view of an emplacement tool and the implantableanchor;

FIG. 15 is a perspective view of the implantable tool mounted on theemplacement tool;

FIG. 16 is a perspective view of the drill guide assembly and theimplantable anchor and emplacement tool prior to insertion within thedrill guide;

FIG. 17 is an enlarged view of the shoulder area illustrating a bonetunnel, and the implantable anchor passed through the bone tunnel andpositioned for attachment to the bare area on the humeral head;

FIG. 18A illustrates the implantable anchor mounted over the tool priorto expansion of the anchor;

FIG. 18B illustrates the implantable anchor as it is deployed;

FIG. 18C is another illustration of the implantable anchor as fullydeployed;

FIG. 19 illustrates the implantable anchor as fully deployed;

FIG. 20 is an enlarged perspective view of a suture and mesh usable inthe apparatus and method of the present invention;

FIG. 21 is another perspective view of the suture and mesh with the meshbeing partially deployed;

FIG. 22 illustrates the suture and mesh combination of FIGS. 20 and 21as fully deployed, along with additional sutures used through tunnels tosecure the mesh; and

FIG. 23 is a perspective view of the suture and mesh combination asinstalled for repair of a rotator cuff injury.

DETAILED DESCRIPTION

Referring to FIG. 1, the drill guide assembly 10 of the presentinvention is illustrated. The drill guide assembly includes a markinghook 12, a drill guide 14, and an angle setting arm 18. The anglesetting arm 18 is secured to one lateral side of a drill guide mount 16.The drill guide 14 is received longitudinally through the drill guidemount 16 and is secured through an open slot in the drill guide mount asby a plurality of set screws 40. The marking hook 12 is secured to theangle setting arm 18 by a marking hook mount 20 which is received at aselected slidable location along the angle setting arm 18. A fastener,such as a wing nut or screw 22 tightens the marking hook mount 20 to aselected angular location along the angle setting arm 18. A plurality ofangular gradations 24 are marked along the angle setting arm 18 thatassists a practitioner in setting the correct location for the markinghook 12. More specifically, a practitioner must determine the length Lof the bone tunnel to be drilled through the humeral head. This length Lis defined as the gap between the hook point 30 of the marking hook 12and the distal end of the drill guide 14. The practitioner alsoselectively locates the position of the drill guide 14 in terms of howfar the distal end of the drill guide extends from the drill guide mount16.

The marking hook 12 is further characterized by a base 34 that comprisesa straight shaft extending from the marking hook mount 20. The distalend of the base transitions into an arcuate extension 32 that isespecially adapted to accommodate the curvature of the humeral head. Thearcuate extension 32 is especially shaped to accommodate the shape ofthe humeral head. The radius of curvature of the humeral head rangesfrom 20 mm to 30 mm. As shown, the extension 32 has a radius R that canbe sized in the 20-30 mm range that allows the surgeon to pass themarking hook arthroscopically around the humeral head and onto the barearea of the far cortical bone. The shape of the extension 32 can bedefined as an arc or semi-circle that traverses approximately 180degrees. This uniquely shaped extension is designed specifically for thehumeral head which has a shape that is very different from the otherjoints in the human body. The marking 12 can also have different shapesfor right versus left shoulders, thus allowing for passage of themarking hook into the glenohumeral joint along the anterior capsule.FIG. 1 shows the shape of the marking hook 12 as best suited for a rightside joint. The hook point 30 extends from the distal tip of the arcuateextension 32 and as shown, the hook point 30 extends in a generaldirection towards the distal end 44 of the drill guide 14.

Referring also to FIG. 2, the drill guide 14 is characterized as havinga shaft 48 with a central bore 80 extending therethrough. The proximalend of the drill guide includes an enlarged portion 46 having anincreased internal diameter opening for receiving a bone drill 60.

In accordance with the bone drill 60 of the present invention, itincludes a drill shaft 62 and a removable drill bit tip 66. The drillbit tip 66 may have a slightly larger diameter than the drill shaft 62such that only the drill bit tip 66 cuts through the bone while thedrill shaft 62 remains slightly spaced from the bone.. The distal end ofthe drill shaft 62 includes a threaded extension 64 that is insertedwithin a threaded well 68 of the drill bit tip 66. When the drill bittip 66 is secured to the drill shaft 62, planar surface 70 of the drillbit tip 66 abuts the facing planar surface 72 of the drill shaft 62.

The particular shape of the drill bit tip 66 is characterized by aplurality of flutes 76 that are formed with a helical pattern on theexterior surface of the drill bit tip 66. The distal tip of the bittapers to form a generally transverse extending cutting edge 78. Thedrill bit tip 66 also includes a transverse aperture or opening 74 thatextends completely through the tip 66. One acceptable size for the drillbit tip 66 is one that has a diameter of approximately 2.5 mm and isapproximately 5.0 mm in length.

Referring to FIG. 4, the drill guide of the present invention isillustrated as it is positioned for use in a rotator cuff repair. Toconduct the repair, first the rotator cuff is held in position, such asby a conventional tissue grasping tool (not shown) that has beeninserted through the skin and deltoid muscle of the patient to reach therotator cuff. Once the rotator cuff is in place, then the drill guide ofthe present invention can be positioned. The practitioner may firstlocate the marking hook 12 to the desired position on the far cortex ofthe humeral head by inserting the marking hook through the tissue in thepatient and placing the tip 30 on the desired exit point on the farcortex. The practitioner may then position the distal end 44 of thedrill guide 14 on the selected location where the practitioner desiresto drill the tunnel. The distal end 44 of the drill guide is then passedthrough the skin, deltoid muscle, and rotator cuff to contact with thehumeral head.

The practitioner drills a first bone tunnel by inserting the drill 60through the bore 80 to drill the bone tunnel. The drill bit tip 66 exitsthe far end of the cortex and is placed directly adjacent the hook point30. The marking hook 12 is then manipulated to insert the hook point 30through the aperture 74 in the drill bit tip 66. The drill shaft 62 isthen unscrewed from the drill bit tip 66 thereby leaving the drill bittip 66 in place as attached to the hook point 30. The use of acannulated marking hook and drill guide for passing of a relay materialcan facilitate the passing of sutures. A cannulation running down thelength of the marking hook allows the surgeon to pass the relay materialto the exit site of the drill. This method and physical guide wouldallow the surgeon to pass suture to the new tunnel placement and allowfor a grasper to be used down the bone tunnel (and possibly the drillguide) to retrieve the suture in sequential steps. The drill guide canhave multiple drilling bores to accommodate different spacing foradjacent bone tunnels and can still incorporate the use of the samemarking hook.

Referring to FIG. 5, the first bone tunnel 86 is illustrated extendingthrough the humeral head. At this point, the practitioner may pass oneor more sutures 88 through the bone tunnel 86. Referring also to FIG.6A, the sutures 88 are passed through the bone tunnel, through theaperture 74 in the drill bit tip, and then are secured to the drill bittip 66 as by a knot 89 that is tied. As shown in FIG. 6A, the drill bittip 66 is located on the bare area 110 on the humeral head 102 andextends transversely across the opening in the bone tunnel to preventthe tip 66 from being pulled back through the tunnel. Accordingly, thelength of the tip 66 is preferably longer than the diameter of the tipso the tip can be used as the transversely placed anchor. By thisprocedure, the drill bit tip serves the dual purpose of drilling thebone tunnel and as the anchor. The opposite ends of the sutures can beattached to the soft tissue around the rotator cuff, such as by softtissue anchors 84.

FIG. 6B illustrates a modified drill bit tip 66 having a pair ofapertures 74. In another method of repair as shown in this Figure, thesutures are passed through the tunnel, through one aperture 74, backthrough the other aperture 74, and then back through the tunnel so thatthe free ends of the sutures are all tied along the superior aspect ofthe greater tuberosity. Thus, there are no knots located at thetip/anchor 66 that further simplifies the procedure by only requiringsuture knots/arrangements at the more easily viewed position along thesuperior aspect of the greater tuberosity.

Referring to FIG. 7, in accordance with another aspect of the presentinvention, a suture 120 is provided that is especially adapted for usein securing sutures in place thereby minimizing staples and otherhardware. As shown in FIG. 7, the suture 120 comprises a plurality offibers woven together to form unexpanded portions 122 interspersed witha plurality of expanded portions 124. The expanded portions arecharacterized by a head or protuberance 126, a gradual sloping frontedge, and a more sharply narrowing back edge 128. The expanded portionsare formed by separating or pulling the strands of material apart fromthe more tightly woven group of fibers in the unexpanded portions 122.The head or protuberance 126 is tapered with respect to the longitudinalaxis of the suture 120.

As shown with the directional arrows, the suture can be passed throughthe bone tunnel or tissue in the direction from right to left as shownin FIG. 7; however, the suture incorporates a grasping feature whichprevents pullout in the direction from left to right. This graspingfeature is achieved by the geometry of the suture in which the heads 126engage the interior surface of the bone tunnel to prevent movement ofthe suture from within the bone tunnel. This pullout or anchoringfeature therefore allows a practitioner to incorporate the suturethrough the bone tunnel and increase frictional resistance of the suturein the bone tunnel that therefore minimizes the forces transmitted toboth the anchor 66, as well as the hardware used to secure the suturesover the deltoid muscle after the procedure has taken place. Thediameter of the suture can be chosen to match the bone tunnel to bedrilled so that optimal frictional resistance is achieved between thesuture and the bone tunnel.

Referring to FIG. 8, a rotator cuff repair is illustrated with referenceto a pair of bone tunnels 86, and a corresponding pair of suture groups,drill bit anchors 66, and soft tissue anchors 84. It shall be understoodthat the practitioner has the option of creating the requisite number ofbone tunnels and suture configurations in order to repair the particularrotator cuff injury.

In accordance with another method of the present invention, the suturescan be passed through one or more bone tunnels after being secured alongthe far cortical bone, then passed through the cuff, tied over the cufftendon, and then passed through one or more additional bone tunnelsalong the lateral aspect of the greater tuberosity back to the farcortical bone.

One particularly challenging type of rotator cuff repair is the repairof a partial thickness cuff tear. An in situ repair can be accomplishedwith the drill guide of the present invention by placing the drill guide14 on top of the tear, passing the drill bit through the tendon, passingthe sutures through the transosseous tunnels and tying knots on top ofthe tendon. As understood by the skilled surgeon, it is very difficultto pass an anchor across the partially intact cuff since the landmarksare hidden from arthroscopic view. The emplacement of the marking hookon the tear therefore obviates the need to see the tuberosity andprovides a precise aiming point for the drill without further imagingand without further incisions made to view the landmarks.

FIG. 9 illustrates a modification to the drill guide assembly 10, whichincludes a cannulated marking hook 12 characterized by a continuousorifice that extends through the marking hook 12. The marking hook 12 asshown also includes a suture 142 that passes through the orifice 140,such that one end of the suture 142 extends through an opening 144 thatcommunicates with the orifice 140. FIG. 11 also illustrates a graspingtool 146 having a handle 148 allowing the practitioner to grasp one endof the tool and insert it through the opening in the drill guide 14.Grasping tines 150 located at the distal tip of the tool 146 can thengrasp the protruding end of the suture 142, so that it may be passedthrough the bone tunnel for purposes of suturing the tissue to berepaired in the surgical procedure.

Also in reference to FIG. 9, the cannulated marking hook 12 allows forany other type of relay material to be passed adjacent the exit point ofthe drill, such as PDS or nitinol wire. The close proximity of the exitpoint of the drill therefore allows for a blind retrieval of the relaymaterial and subsequent suture passing, with a minimized need forvisualizing the area. In other words, because the drill tip willintersect the marking hook tip, use of a tool like the illustratedgrasping tool 146 allows a practitioner to easily retrieve relaymaterial in somewhat of a blind fashion which thereby greatly eases inthe commencement of the suture passing.

FIG. 10 illustrates a modified drill guide 14 including a pair of bores160. This dual set of bores within the drill guide 14 allow thepractitioner additional options in setting offset distances toaccommodate different drill positions to address different rotator cufftear patterns.

Referring to FIG. 11, another modification is shown to the marking hook12. This modification includes two separate orifices 140 that extendcompletely through the marking hook 12. One of the orifices 140terminates at intermediate opening 176. The other orifice terminates atdistal opening 174. As also shown in the figure, two sets of sutures 172extend through the orifices 140. A marking hook having multiple offsetending points at the openings 174 and 176 allows for convenient relayretrieval at different designated offset aiming points. For example,there may be multiple bone tunnels formed through the humeral head, andit may be necessary to relay sutures through each of the bone tunnels.The openings 174 and 176 may be centered over the bone tunnelspreviously drilled, which therefore allows for convenient relayretrieval without having to reposition the marking hook numerous times.

Referring to FIGS. 12 and 13, in another aspect of the invention, animplantable anchor is provided that can be used to anchor sutures, suchas those that extend through a bone tunnel. The implantable anchor 180includes a cylindrical shaped body/cage 182, and a plurality ofcircumferentially spaced and longitudinally extending slits or openings186. Approximately midway between the distal end 188 and the proximalend 190 of the anchor is a weakened area forming a score line 192.Adjacent the distal end 188 of the anchor are a plurality of openings184 that receive one or more sutures 194, as shown in FIG. 13.

Referring to FIG. 14, an inserting tool 200 is shown that is used toemplace the anchor 180. The inserting tool 200 includes a proximal body202, a distal tip 206 having a diameter which is less than the body 202,as defined by the shoulder 204 which delineates the distal end of thebody 202 and the proximal end of the tip 206.

Referring also to FIG. 165, the anchor 180 is positioned over the tip206, and the sutures 194 extend proximally as shown.

Referring to FIG. 16, the anchor 180 is shown in its mounted positionover the tool 200, and the tool 200 is then inserted through the drillguide 14. The tool 200 has a length which accommodates the combinedlength of the drill guide 14 and bone tunnel 86, so that the anchor 180can be placed completely through the bone tunnel and beyond the far sideof the joint, as shown in FIG. 17. Once the anchor 180 has cleared thebone tunnel, the anchor can be activated to secure the sutures. Onemethod of employment of the anchor is to keep the anchor 180 mountedover the tool 200 as explained below with respect to FIGS. 180A through18C. Another method of employment is to release the tool 200 fromengagement with the anchor 180 after the anchor 180 has passed throughthe bone tunnel, as also explained below.

In order to deploy the anchor 180, the practitioner will pull proximallyon the sutures 194 thereby placing them in tension, and causing theanchor 180 to collapse along the score line 192. As shown in FIG. 18A,the sutures are initially without tension, and then tension is placedupon them as shown in FIG. 18B causing the collapse of the anchor.Referring to FIG. 18C, tension is continually applied to fully collapsethe anchor along the score line 192. As the anchor collapses, itincreases in overall diameter, thereby preventing the anchor 180 frombeing pulled back through the bone tunnel. Preferably, the diameter ofthe anchor 180 is just slightly smaller than the diameter of the bonetunnel, such that minimal collapse of the anchor will prevent it frombeing pulled back through the bone tunnel. The length of the anchor 180can be approximately 10 mm in length, which will accomplish thenecessary anchoring capability for most bone tunnels.

As shown in FIG. 19, the anchor 180 has been deployed to its fullycollapsed position. The sutures 194 can then be tied/secured at theopposite end of the bone tunnel.

Although only two pairs of sutures 194 are illustrated, additionalsutures may be secured through the openings 184 in the anchor 180,depending upon the manner in which the sutures are used for the specificsurgical procedure. It is clear from the figures that it is onlynecessary for one suture 194 for activation/deployment of the anchor180. It is noted in FIG. 17 that the tool 200 is not illustrated, itbeing understood that the tool 200 would extend completely through thebone tunnel, and would remain in engagement with the anchor 180 untilthe anchor was expanded in a diameter to prevent pull back through thebone tunnel 86.

Referring to FIG. 20, in another aspect of the invention, a sutureconstruction is provided in the form of a mesh canopy 222 that can beinitially retained on a conventional suture 220.

As shown in FIG. 21, the mesh canopy 222 can be unfurled from a rolledposition about the supporting suture 220. The mesh canopy 222 can thenbe appropriately positioned over the damaged tissue in order to providea much larger area for support, as compared to a conventional suturearrangement.

As shown in FIG. 22, once the mesh canopy 222 has been deployed, it mayextend away from the supporting suture 220 in a fashion to providegreater coverage over a targeted area. A plurality of openings 224 maybe formed around the edge of the mesh canopy 222, and these openings 224may receive a desired set of sutures 226 that may pass through bonetunnels formed in the joint, as shown in FIG. 24.

In the example of FIG. 23, there are four bone tunnels that have beenprovided through the bone structure, and the pairs of sutures 226 extendin a looped fashion through adjacent pairs of the bone tunnels. Thesutures 226 can then be secured over the mesh 222 as by use of securingknots 228. Optionally, the supporting suture 220 may also be secured tothe tissue as by tissue anchors 84.

It is clear from the present invention that an effective repair of arotator cuff injury can be achieved that minimizes traditional boneanchors, and rather incorporates a minimal amount of hardware andsimplifies suture arrangements.

Thus, in accordance with the present invention, a rotator cuff repaircan be achieved where anchoring of the sutures avoids the cancellousbone mass located beneath the near cortex of the bone in favor ofanchoring the sutures at the far cortex of the bone that has a higherbone density. By the use of an especially adapted marking hook, the bonetunnels can be very precisely determined enabling more than one bonetunnel to be created through the bone mass in order to handle theparticular rotator cuff injury at hand. Separate bone anchors arereplaced in favor of anchoring sutures by the drill bit tip 66 on thefar cortex.

Also in accordance with the present invention, unique sutureconstructions are provided that provide a practitioner with many optionsfor stabilizing torn tissue to include minimizing the stresses producedon bone and soft tissue anchors. A unique anchor is also provided thatcan be deployed without the use of further instruments, and which isintroduced directly through the bone tunnels.

Furthermore, the method of the present invention can be achieved with aminimum of instruments thereby making the procedure of the presentinvention more susceptible to repeatability and reliability.

While the present invention has been described with respect to preferredembodiments in accordance with the apparatus and method of the presentinvention, various other changes may be made within the scope of theclaims appended hereto.

1. A method of arthroscopic repair of a rotator cuff, said methodcomprising: providing a drill guide assembly including a marking hook,an angular setting arm, and a drill guide; positioning the drill guideassembly for drilling a hole through the humeral head; providing a bonedrill having a drill shaft and a removable drill bit tip; inserting thebone drill through the drill guide; drilling a bone tunnel through thehumeral head; disengaging the drill bit tip from the drill shaft;securing the drill bit tip with the marking hook; passing suturesthrough the bone tunnel and securing a distal end of the sutures throughan aperture formed in the drill bit tip; and securing the opposite endof the sutures on soft tissue surrounding the rotator cuff.
 2. A systemfor repair of a rotator cuff injury, said system comprising: a drillguide assembly including a marking hook, an angular setting arm, and adrill guide; a drill having a removable drill bit tip placed throughsaid drill guide for drilling a bone tunnel, said drill bit tip beingplaced at one end of a bone structure through which the bone tunnel hasbeen drilled; and at least one suture passing through the bone tunneland secured to said drill bit tip when said drill bit tip is disengagedfrom said drill, said suture being secured at the opposite end of thebone tunnel to at least one soft tissue anchor emplaced on soft tissuesurrounding the rotator cuff.
 3. A suture comprising: a plurality offibers woven together, said fibers forming a plurality of unexpandedportions interspersed with a plurality of expanded portions, wherein theexpanded portions include a protuberance, each protuberance having agradual sloping front edge, and a sharply narrowing back edge.
 4. Asystem, as claimed in claim 2, wherein: said marking hook has an orificeextending therethrough, and wherein said at least one suture alsoextends through said orifice prior to passing through the bone tunnel.5. A system, as claimed in claim 2, wherein: said drill guide includes apair of bores extending therethrough, said bores being spaced from oneanother along a length of said drill guide.
 6. A system, as claimed inclaim 2, wherein: said marking hook has an orifice extendingtherethrough, and said marking hook further includes an intermediateopening and a spaced distal opening, said intermediate and distalopenings for receiving a suture extending therethrough.
 7. Animplantable anchor especially adapted for anchoring sutures used in asurgical procedure, said implantable anchor comprising: a cylindricalshaped body, a plurality of circumferentially spaced and longitudinallyextending slits extending through said body, at least one opening formedon said body and positioned adjacent a distal end of said body, and ascore line formed circumferentially about said body enabling said anchorto collapse about said score line.
 8. A system for implanting an anchorespecially adapted for anchoring sutures used in a surgical procedure,said system comprising: a cylindrical shaped body, a plurality ofcircumferentially spaced and longitudinally extending slits extendingthrough said body, at least one opening formed on said body andpositioned adjacent a distal end of said body, and a score line formedcircumferentially about said body enabling said anchor to collapse aboutsaid score line; and an inserting tool engaged with said anchor, saidinserting tool having a distal end extending through said anchor.
 9. Amethod of activating an implantable anchor used in a surgical procedure,said method comprising the steps of: providing an anchor comprising acylindrical shaped body, a plurality of circumferentially spaced andlongitudinally extending slits extending through said body, at least oneopening formed on said body and positioned adjacent a distal end of saidbody, and a score line formed circumferentially about said body enablingsaid anchor to collapse about said score line; providing an insertingtool engaged with said anchor, said inserting tool having a distal endextending through at least a portion of said anchor; positioning theanchor at a desired location; providing at least one suture secured tosaid anchor by routing said suture through one of said openings of saidanchor; collapsing the anchor about said score line by tension appliedfrom said suture, wherein an effective diameter of said anchor increasesthereby securing the anchor in place; and removing the inserting toolfrom engagement with said anchor.
 10. A suture comprising: a firstsuture element; a second suture element secured to said first sutureelement, said second suture element comprising a mesh canopy rolledabout said first suture element, said mesh canopy being deployable fromsaid first suture element in an arrangement to cover a designated areaof tissue.
 11. A suture combination comprising: a first suture element;a second suture element secured to said first suture element, saidsecond suture element comprising a mesh canopy rolled about said firstsuture element, said mesh canopy being deployable from said first sutureelement in an arrangement to cover a designated area of tissue; and aplurality of suture passes communicating with said mesh canopy, saidsuture passes being oriented substantially perpendicular to said meshcanopy, and said suture passes extending through bone tunnels formed ina bone structure.
 12. A method of activating an implantable anchor usedin a surgical procedure, said method comprising the steps of: providingan anchor comprising a cylindrical shaped body, a plurality ofcircumferentially spaced and longitudinally extending slits extendingthrough said body, at least one opening formed on said body andpositioned adjacent a distal end of said body, and a score line formedcircumferentially about said body enabling said anchor to collapse aboutsaid score line; providing at least one suture secured to said anchor byrouting said suture through one of said openings of said anchor; routingthe anchor and the at least one through a bone tunnel and positioningthe anchor beyond a distal end of the bone tunnel; and collapsing theanchor about said score line by tension applied from said suture,wherein an effective diameter of said anchor increases thereby securingthe anchor in place and preventing the anchor from being routed backthrough the bone tunnel.